Dublin City School District
Waiver/Appeal Form
for Academic Eligibility
in Athletics and Extracurricular Activities
This is a request for:
•
•
•
•
Waiver _____
Program
2430 F1
Revised 1/15/15
Page 1 of 2
Appeal _____
If this is a request for a waiver, submit to building principal for review by Eligibility Board
If this is a request for an appeal, submit for review by the Superintendent or his/her designee
Be sure to complete both page 1 and page 2 of this form
Once a decision has been made, a copy of this form will be sent to the parent/guardian with a letter stating the
status of the student’s eligibility
Student name: _______________________________________________________________________
Age: ___________
Grade: ___________
Phone number: _______________________
Home address: ______________________________________________________________________
Parent/Guardian: _____________________________________________________________________
Sport/Activity: ___________________________
Number of waivers:
☐ 1st
☐ 2nd
Coach/Advisor: ___________________________
☐ 3rd
additional: _________________
Reason for request: please list any special circumstances or condition, which may have contributed to your GPA.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Parent signature: _________________________
Student signature: _________________________
Finding of the Eligibility Board
The Eligibility Board met on __________________________ and ☐ granted / ☐ denied the request
to waive academic eligibility criteria.
Comments: _________________________________________________________________________
___________________________________________________________________________________
Eligibility Board Member signature: _____________________________________________________
Title: ________________________________________
Date: ______________________________
Any student appeal of the Eligibility Board’s decision must be made within five days of the receipt of
the Board’s decision. Such appeals will be filed at the Central Administration Office and acted upon by
the Superintendent or his/her designee.
Student’s name: ____________________________________________
Program
2430 F1
Revised 1/15/15
Page 2 of 2
No Academic Eligibility Waivers will be considered without a thorough
student response to the following.
In the space below, please write a detailed explanation about what you plan to do to correct your current
academic situation. Be sure to include what is causing your current academic situation and the specific
modification(s) you will follow to correct the problem.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Eligibility board members consider the following when contemplating the waiver.
Check if acceptable:
☐ Did the student address their current problem thoroughly?
☐ Did the student give an accurate and detailed plan with specific modifications to correct the
current problem?
☐ Did the student demonstrate a genuine desire to correct the problem?
☐ Is the above plan thorough and comprehensive enough to actually make a difference?